The relationship between demoralization and depressive symptoms among patients from the general hospital: network and exploratory graph analysis

Demoralization: A concept analysis through a scoping review methodology

Background

Demoralization is a complex construct comprising of several clinical phenomena that has gained increasing interest in clinical practice and research; however, the concept needs to be sufficiently specified and clearly described. A concept analysis of demoralization is necessary to integrate previous research findings and establish the scientific foundation for future intervention research.

Aim

To analyze the concept of demoralization in terms of its antecedents, attributes, consequences, and empirical referents in health.

Methods

A concept analysis was performed using the Joanna Briggs Institute guidelines scoping review method and mapping information through the Walker and Avant concept analysis framework. Electronic databases, including PubMed, The Cochrane Library, Embase, PsycINFO, and Web of Science, were searched until September 15, 2024. The grey literature and other minor non-indexed publications were also reviewed.

Results

A total of 106 articles were included in the review. Antecedents included medical illness, symptom burden, low social support and coping difficulties. Attributes were identified as follows: dysphoria, disheartenment, helplessness, hopelessness, loss of meaning and purpose, and sense of failure. Consequences included poor quality of life, depression, anxiety, suicidal ideation and desire to die. The concept of demoralization was illustrated through a model case, one exhibiting borderline criterion and another displaying challenge.

Conclusion

This scoping review clarifies the clinical definition of demoralization, distinguishing it from common language usage and from other emotional symptoms frequently experienced by patients.

Implications for Practice

The identified attributes of demoralization play vital roles in health assessments and should guide nurses in providing appropriate patient care early on. Interventions should address the concept's antecedents and consequences.

Assessing the dimensions and structure of thwarted interpersonal needs

INTRODUCTION

The Interpersonal Needs Questionnaire-15 (INQ-15) assesses interpersonal needs comprising suicidal desire based on the Interpersonal Theory of Suicide (IPTS): Thwarted belongingness (TB) and perceived burdensomeness (PB). The IPTS is applied to many psychological-affective states and disorders, collectively showing state-specific pathways to suicidal features. Given the prevalent application of the IPTS, determining how the constructs are comprised and operate is critical. Consistent with the network perspective of psychological constructs, we used network and algorithmic methods to evaluate thwarted interpersonal needs.

METHODS

A sample (N = 863) aggregated from two independent studies (Sokol & Serper, 2019; Sokol et al., 2023) was used for analysis.

RESULTS

Network analysis identified three dimensions that were invariant by suicide-risk status: PB, and two dimensions from the TB items. Accounting for wording effects, one-dimensional structures presented in 9 %-23 % of replicates. The loadings comparison test algorithm suggested that the constructs were consistent with a network composition (over latent), and centrality indices identified meaningful strong and bridge features.

LIMITATIONS

The samples were demographically homogeneous, and more diverse samples in terms of sexuality, racial/ethnic identification, culture, and socioeconomic status might yield different findings.

CONCLUSION

Findings indicate that thwarted interpersonal needs are comprised of perceived burdensomeness, loneliness, and absence of reciprocal care dimensions and that loneliness-related experiences may be mechanisms by which PB and TB-related experiences co-occur. Additionally, results showed that the INQ-15 may have previously unquantified method effects, but the overall identified dimensions are stable. These results yield a nuanced conceptualization of interpersonal needs and their function.

Demoralization's link to depression and anxiety symptoms: A network analysis

Demoralization represents a clinical syndrome conceptualized as maladaptive coping to a stressor associated with discouragement, feelings of hopelessness, helplessness, and a loss of meaning in life. It is a prevalent comorbidity in individuals with severe physical illnesses and affects a substantial proportion of the general population when facing global stressors like the COVID-19 pandemic. The main aim of the study was to test whether demoralization and features of depression and anxiety might reflect distinct entities within the general population, specifically in older adults, and to explore symptom interconnections, using a network psychometrics approach. The revised demoralization scale (DS-II) and the patient health questionnaire 4 (PHQ-4) were applied to a representative sample (N = 2434) from the German general population. Network structures were analyzed using exploratory graph analysis (EGA) to identify the most distinct symptom groupings and their relationships. Stability of networks and symptom groupings was tested using bootstrap procedures. EGA revealed unidimensionality within younger adulthood and a four-factor solution within older adults, reliably distinguishing PHQ-4 and DS-II items. The most central features of the network were worthlessness, pointlessness, helplessness, feeling trapped and low mood. Suicidal ideation was more closely related to DS-II worthlessness than to PHQ-4 items. The cross-sectional design and using PHQ-4 instead of more comprehensive measures of depression and anxiety were limitations. In conclusion, in general population, demoralization symptoms can be distinguished from lack of interest or pleasure and low mood. It might represent a valid psychological construct beyond clinical populations. Further investigation of diagnostic implications is encouraged.

A tale of two constructs: combined assessment of demoralization and subjective incompetence

Demoralization comprises multiple dimensions. Among them, Subjective Incompetence (SI) is the perception of being incapable of appropriate action in demanding circumstances. SI may be an early sign of demoralization preceding hopelessness, thus we aimed at integrating items related to Subjective Incompetence into the clinical assessment of demoralization. We assessed 414 subjects from the general population with the Demoralization Scale, 24 items (DS24) and the Subjective Incompetence Scale, 12 items (SIS12). We used multiple approaches to detect the optimal number of factors and their item structure, then conducted Bayesian Item Response Theory analyses to study item psychometric properties. Item Response Theory models were used to extrapolate latent severity ratings of clinical dimensions. We modelled the DS24 with five factors (Disheartenment, Sense of Failure, Helplessness, Irritability, Loss of Purpose) and the SIS12 with three (Subjective Incompetence, Inability to plan, Inability to Deal). The more complex IRT model had the best predictive value and helped to identify the items with better discrimination properties across the different dimensions. Twenty items were retained and used to develop the combined Demoralization and Subjective Incompetence Scale (DSIS20), which maintained high correlation with raw and latent trait scores of the longer versions. We combined selected items of the DS24 and the SIS12 to develop the DSIS20, a shorter assessment instrument that includes Subjective Incompetence as well as other clinical dimensions of demoralization. Further study may clarify if DSIS20 may be helpful for the early detection of demoralization.

Relationship Between Chronic Obstructive Pulmonary Disease Exacerbations and Depression

BACKGROUND AND OBJECTIVES

Depressive episodes are frequent in chronic obstructive pulmonary disease (COPD) patients. These episodes are related to a vast number of clinical and psychosocial variables. Nevertheless, the relationship between the number of COPD exacerbations and depression has not been extensively studied in the Colombian Caribbean. The objective was to determine the relationship between COPD exacerbations and depression in a sample of outpatients in Santa Marta, Colombia.

METHODS

A cross-sectional analytical study was designed in which COPD adult patients participated. The number of COPD exacerbations (none versus one or more) and the risk of depression were documented. The crude and adjusted association was established by calculating the odds ratios (OR) and 95% confidence interval (95%CI).

RESULTS

The study included 408 patients aged between 40 and 102 years (mean 72.9±10.2), and 58.8% were male. 105 patients (25.9%) reported one or more exacerbations in COPD, and 114 patients (27.9%) were at risk for depression. The crude relationship between exacerbations and depression was statistically significant (OR=1.80; 95%CI, 1.12-2.89) and after adjusting for sex (OR=1.99; 95%CI, 1.23-3.23).

CONCLUSIONS

The number of COPD exacerbations among outpatients in Santa Marta, Colombia is related to depression. Longitudinal studies are needed in Colombia.

Implementation of the psycho-existential symptom assessment scale in palliative care: Qualitative analysis of stakeholders perspectives

OBJECTIVES

To explore 1) perspectives of feasibility, acceptability, integration and sustainability of the Psycho-existential Symptom Assessment Scale (PeSAS); 2) barriers and benefits of PeSAS in its real-world performance; and 3) clinician confidence and perceived competency in using PeSAS.

METHODS

Thirty-one key stakeholders from nine palliative care services who participated in the implementation of the PeSAS were purposefully sampled and participated in semi-structured interviews. Data was managed using the Determinants Framework.

RESULTS

Benefits of PeSAS were a common language enhancing communication, identifying symptoms of psycho-existential distress, initiating referral, providing acknowledgement for previously unrecognised distress and enhancing patient agency. Key barriers were the availability of skilled clinicians, patient characteristics such as delirium and phase of illness, avoidance of confronting end-of-life conversations, information technology resourcing, and reduced engagement due to language, culture and health literacy.

CONCLUSION

Screening using the PeSAS is feasible and acceptable once clinicians are adequately trained to administer it. Our study highlights the benefits of qualitative enquiry in developing and implementing new interventions.

PRACTICE IMPLICATIONS

The identification and management of psycho-existential symptoms should be part of routine practice in palliative care. However, adequate staff training, resourcing, referral pathways and implementation process and outcome assessments are important to ensure sustainability.

Prevalence and factors associated with demoralization in palliative care patients: A cross-sectional study from Hong Kong

OBJECTIVES

Although demoralization is common among palliative care patients, it has not yet been examined empirically in the Hong Kong Chinese context. This study aims to examine (1) the prevalence of demoralization among community-dwelling palliative care patients in Hong Kong; (2) the percentage of palliative care patients who are demoralized but not depressed and vice versa; and (3) the association of socio-demographic factors, particularly family support, with demoralization.

METHOD

A cross-sectional study targeting community-living palliative care patients in Hong Kong was conducted. A total of 54 patients were recruited by a local hospice and interviewed for completing a questionnaire which included measures of demoralization, depression, perceived family support, and demographic information.

RESULTS

The prevalence of demoralization was 64.8%. Although there was overlap between demoralization and depression (52.8% meeting the criteria of both), 7.5% of depressed patients were not demoralized, and 13.2% of demoralized patients were not depressed. Participants who were not single and had more depressive symptoms and less family support had a significantly higher demoralization level.

SIGNIFICANCE OF RESULTS

This is the first study which reports the prevalence of demoralization in Hong Kong. Demoralization was found common in community-living palliative care patients receiving medical social work services in Hong Kong. This study provides evidence of the importance of differentiating the constructs between demoralization and depression. It also provides an implication that those who are married, more depressed, and have the least family support could be the most vulnerable group at risk of demoralization. We recommend that early assessment of demoralization among palliative care patients be considered.

The body of evidence of late-life depression: the complex relationship between depressive symptoms, movement, dyspnea and cognition

BACKGROUND

Physical symptoms play an important role in late-life depression and may contribute to residual symptomatology after antidepressant treatment. In this exploratory study, we examined the role of specific bodily dimensions including movement, respiratory functions, fear of falling, cognition, and physical weakness in older people with depression.

METHODS

Clinically stable older patients with major depression within a Psychiatric Consultation-Liaison program for Primary Care underwent comprehensive assessment of depressive symptoms, instrumental movement analysis, dyspnea, weakness, activity limitations, cognitive function, and fear of falling. Network analysis was performed to explore the unique adjusted associations between clinical dimensions.

RESULTS

Sadness was associated with worse turning and walking ability and movement transitions from walking to sitting, as well as with worse general cognitive abilities. Sadness was also connected with dyspnea, while neurovegetative depressive burden was connected with activity limitations.

DISCUSSION

Limitations of motor and cognitive function, dyspnea, and weakness may contribute to the persistence of residual symptoms of late-life depression.

Network Psychometrics of the 10-Item Perceived Stress Scale Among Patients With High Cardiovascular and Type 2 Diabetes Risk Using Exploratory Graph Analysis

BACKGROUND

No studies have explored the internal structure of the 10-item Perceived Stress Scale in patients with high cardiovascular and diabetes risk.

OBJECTIVE

We scrutinized the dimensionality of the scale in this patient group using exploratory graph analysis, a technique within the developing field of network psychometrics.

METHODS

Analyses were conducted on 200 primary care patients. A bootstrap version of exploratory graph analysis assessed the stability of the dimensions based on structural consistency, item stability, and network loadings.

RESULTS

Exploratory graph analysis revealed a 2-dimensional structure; structural consistency of the first dimension was high (0.863), whereas that for the second was low (0.667). Items belonging to the latter dimension did not cluster consistently with each other (ie, low item stability) and were not strongly associated with any particular dimension (ie, weak network loadings).

CONCLUSION

Exploratory graph analysis offers unique outputs, making it easy to assess the dimensional integrity of scales. Further research is warranted regarding the second dimension of the Perceived Stress Scale.

Prevalence, Associated Factors and Adverse Outcomes of Demoralization in Cancer Patients: A Decade of Systematic Review

Demoralization has been extensively studied in oncology and palliative care settings, and is characterized by a loss of meaning and purpose in life, a sense of powerlessness over life events, and a sense of helplessness. The objective of this systematic review is to synthesize the prevalence, associated factors, and adverse outcomes of demoralization in cancer patients by reviewing the literature of the last decade. Seven databases (PubMed, PsycINFO, Embase, Web of Science, Medline, CINAHL and Cochrane Library databases) were systematically searched from January 2012 to June 2022. Roughly speaking, the prevalence of demoralization in cancer patients ranges from 13.50% to 49.4%. A total of 45 factors are associated with demoralization, of which psychological factors have been studied more frequently in the last decade. There are nine outcomes related to demoralization, with the strongest evidence for the correlation between demoralization and suicidal ideation. The study emphasizes the complexity of factors associated with demoralization in cancer patients. There appears to be a intersection between the constructs of demoralization and depression, anxiety, and suicidal ideation, which may explain the correlation between them.

Real World Experience of Change in Psycho-Existential Symptoms in Palliative Care

CONTEXT

Psycho-existential symptoms in palliative care are addressed insufficiently. Routine screening, ongoing monitoring and meaningful treatment of psycho-existential symptoms may contribute to the relief of suffering in palliative care.

OBJECTIVES

We sought to explore longitudinal change in psycho-existential symptoms following the routine implementation of the Psycho-existential Symptom Assessment Scale (PeSAS) in Australian palliative care services.

METHODS

Using a multisite rolling design, we implemented the PeSAS to longitudinally monitor symptoms in a cohort of 319 patients. We assessed change scores for each symptom in groups with mild (≤3), moderate (4-7) and severe (≥8) symptomatology at baseline. We tested significance between these groups and used regression analyses to identify predictors.

RESULTS

While one half of patients denied clinically important psycho-existential symptoms, for the remainder, overall, more patients improved than deteriorated. Between 20% and 60% of patients with moderate and severe symptoms improved, while another 5%-25% developed new symptom distress. Patients with severe baseline scores improved significantly more than those with moderate baseline scores.

CONCLUSION

As we better recognize through screening patients carrying psycho-existential distress in palliative care programs, there is considerable room for improvement in ameliorating this suffering. Inadequate clinical skills, poor psychosocial staffing or a biomedical program culture may all contribute to inadequate symptom control. Person-centered care necessitates greater attention to authentic multidisciplinary care that ameliorates psycho-spiritual and existential distress.

Patterns of demoralization and anhedonia during early substance use disorder treatment and associations with treatment attrition

BACKGROUND

Although depressive symptoms represent a promising therapeutic target to promote recovery from substance use disorders (SUD), heterogeneity in their diagnostic presentation often hinders the ability to effectively tailor treatment. We sought to identify subgroups of individuals varying in depressive symptom phenotypes (i.e., demoralization, anhedonia), and examined whether these subgroups were associated with patient demographics, psychosocial health, and treatment attrition.

METHODS

Patients (N = 10,103, 69.2 % male) were drawn from a dataset of individuals who presented for admission to SUD treatment in the US. Participants reported on their demoralization and anhedonia approximately weekly for the first month of treatment, and on their demographics, psychosocial health, and primary substance at intake. Longitudinal latent profile analysis examined patterns of demoralization and anhedonia with treatment attrition as a distal outcome.

RESULTS

Four subgroups of individuals emerged: (1) High demoralization and anhedonia, (2) Remitting demoralization and anhedonia, (3) High demoralization, low anhedonia, and (4) Low demoralization and anhedonia. Relative to the Low demoralization and anhedonia subgroup, all the other profiles were more likely to discontinue treatment. Numerous between-profile differences were observed with regard to demographics, psychosocial health, and primary substance.

LIMITATIONS

The racial and ethnic background of the sample was skewed towards White individuals; future research is needed to determine the generalizability of our findings to minoritized racial and ethnic groups.

CONCLUSIONS

We identified four clinical profiles that varied in the joint course of demoralization and anhedonia. Findings suggest specific subgroups might benefit from additional interventions and treatments that address their unique mental health needs during SUD recovery.

The Italian validation of the Death and Dying Distress Scale

OBJECTIVES

Death anxiety (DA), a condition characterized by fear, angst, or panic related to the awareness of one's own death, is commonly observed in advanced cancer patients. The aim of this study was to examine the psychometric properties of the Italian version of the Death and Dying Distress Scale (DADDS-IT) in a sample of patients with advanced cancer.

METHODS

The sample included 200 Italian advanced cancer patients meeting eligibility criteria to access palliative care. Patients' levels of DA were assessed by using the DADDS-IT, while the levels of depression, anxiety, demoralization, spiritual well-being, and symptom burden were assessed using the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, the Demoralization Scale, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale, and the Edmonton Symptom Assessment System, respectively; Karnofsky Performance Status was used to measure functional impairment. Confirmatory factor analyses (CFA) of previous structures and exploratory factor analyses (EFA) were conducted.

RESULTS

CFA revealed that none of the previous structures adequately fitted data from our sample. EFA revealed a 4-factor model comprising Finitude (α = 0.91), Regret (α = 0.86), Dying (α = 0.88), and Relational Burden (α = 0.73), accounting for the 77.1% of the variance. Dying subscore was higher in hospice patients than in those recruited in medical wards.

SIGNIFICANCE OF RESULTS

The present study provides further evidence that DA is a condition that deserves attention and that DADDS-IT shows good psychometric properties to support its use in research and clinical settings.

Anxiety and depression in adult cancer patients: ESMO Clinical Practice Guideline

•Anxiety and depressive disorders are common in patients with cancer. •A higher prevalence seen in patients with cancer than the general population is often underrecognised. •Psychotherapy, cognitive behavioural therapy and mindfulness-based therapies are effective treatments. •Psychopharmacological treatments have been shown to be effective treatments of anxiety and depressive disorders.

Clinical utility of demoralization: A systematic review of the literature

Demoralization is a complex clinical phenomenon which has raised a growing interest in clinical and research realms. The present systematic review of the literature aimed at (1) updating on demoralization prevalence in different populations, (2) identifying the instruments more largely used to assess demoralization, and (3) verifying whether new tools of assessment have been proposed. PubMed and Web of Science were searched from inception to April 2022. Search terms were: demoralization/demoralized/demoralizing/demoralised/demoralising. PRISMA guidelines were followed. GRADE rating system was used. A total of 188 papers were included. Demoralization appeared to be a distinctive psychological state common in medical, psychiatric, and non-clinical settings, thus not limited to life-threatening diseases. Diagnostic Criteria for Psychosomatic Research (DCPR) and Demoralization Scale (DS) are the most commonly used tools to assess it. DCPR allow to diagnose demoralization as a manifestation of dealing with chronic stress. DS captures dimensionally a psychological distress related to end of life. Demoralization is associated with clinical features encompassing allostatic overload, quality of life, wellbeing/euthymia. Implications on health outcomes and treatment are discussed. Demoralization warrants careful consideration in clinical contexts through valid assessment procedures. DCPR are recommended to diagnose it, DS can be helpful to capture clinical details.

The facets of psychopathology in patients with cancer: Cross-sectional and longitudinal network analyses

OBJECTIVE

Cancer patients display heterogeneous psychopathology, comprising depressive, anxiety, hostility, and somatic symptoms. Often, clinical pictures evolve over time deteriorating the individual functioning and prognosis. Network models can reveal the relationships between symptoms, thus providing clinical insights.

METHOD

This study examined data of the Brief Symptom Inventory and the Distress Thermometer, from 1108 cancer outpatients. Gaussian Graphical Models were estimated using regularized and non-regularized Bayesian methods. In addition, we used community detection methods to identify the most relevant symptom groupings, and longitudinal network analyses on 515 participants to examine the connections between symptoms over three months.

RESULTS

The network models derived from baseline data suggested symptoms clustered into three main complexes (depression/anxiety, hostility, and somatic symptoms). Symptoms related to depression and hostility were highly connected with suicidal and death thoughts. Faintness, weakness, chest pain, and dyspnoea, among somatic symptoms, were more strongly connected with psychopathological features. Longitudinal analyses revealed that sadness, irritability, nervousness, and tension predicted each other. Panic and death thoughts predicted fearfulness and faintness.

CONCLUSIONS

Somatic symptoms, sadness, irritability, chronic and acute anxiety interact between each other, shaping the heterogeneous clinical picture of distress in cancer. This study, strengthened by robust methods, is the first to employ longitudinal network analyses in cancer patients. Further studies should evaluate whether targeting specific symptoms might prevent the onset of chronic distress and improve clinical outcomes in cancer patients.

The structure of eating disorder and somatic symptoms

Individuals with eating disorders (EDs) often present with somatic concerns in treatment, such as bloating, fullness, and feeling tight clothes on skin. However, most research generally focuses on general interoception (e.g., heartbeat) rather than sensations relevant to EDs (e.g., sensations related to the gastrointestinal system or body movement). In the current study (N = 181), we used network analysis to model the structure of ED symptoms and somatic concerns among individuals with anorexia nervosa, bulimia nervosa, and other specified feeding and eating disorder. Results showed that heightened sensitivity to somatic concerns had the highest strength centrality within a symptom network comprising ED and somatic symptoms. Exploratory graph analysis identified four symptom dimensions: cognitive-affective ED symptoms, behavioral ED symptoms, general interoception, and ED-specific proprioception. Findings suggest that heightened sensitivity to somatic concerns may maintain ED symptoms and mutually reinforce other somatic concerns. Implications concerning assessment and treatment of EDs are discussed.

Psycho-Existential Symptom Assessment Scale (PeSAS) Screening in Palliative Care

CONTEXT

Psycho-existential symptoms are common yet often missed or neglected in palliative care. Screening can be an effective way to recognize and respond to this need.

OBJECTIVES

We aimed to implement routine use of the Psycho-existential Symptom Assessment Scale (PeSAS) as a screening tool in Australian palliative care services and discern the symptom prevalence identified.

METHODS

In a multi-site rolling design, we established implementation site committees and embarked on experiential workshops to train clinicians in the tool's efficient use. Patient symptom prevalence data were collected to compare uptake across sites. Descriptive statistics were applied.

RESULTS

Over one year, we trained 216 clinicians across six palliative care services in the use of the PeSAS as a screening tool and collected data from 1405 patients. Clinicians reported significant growth in their sense of efficacy in assessing psycho-existential wellness. Services using electronic records implemented most easily. Psycho-existential symptoms with clinically significant prevalence (scores ≥ 4/10) included anxiety 41.1%, discouragement 37.6%, hopelessness 35.8%, pointlessness 26.9%, depression 30.3%, and the wish to die 17%. The precision of measurement within 3% was found for severe ratings (score ≥ 8/10) including anxiety 10.6%, depression 10.2%, the wish to die 7.6%, and confusion 3.6%.

CONCLUSION

Clinicians can be trained to screen with the Psycho-existential Symptom Assessment Scale, which serves as a valuable measure to better recognize symptoms of psycho-existential distress among palliative care patients. Implementation barriers included the prior ethos of the service, confidence in talking about these themes, electronic data entry, and perceived time pressures.

The Body, the Mind, and the Spirit: Including the Spiritual Domain in Mental Health Care

This article supports the expansion of Engel's (Science (AAAS) 196(4286):129-136, 1977) biopsychosocial model into a biopsychosocial-spiritual model, as Sulmasy (The Gerontologist 42(5):24-33, 2002) and others have suggested. It utilizes case studies to describe five areas of clinical work within mental health (religious grandiosity, depression and grief, demoralization and suicidality, moral injury, and opioid use disorder) with emerging evidence for the inclusion of the spiritual domain in addition to the biological, psychological, and social. For each clinical area, an underutilization of the spiritual domain is compared with a more developed and integrated use. An argument is made for continuing to develop, understand, and utilize a biopsychosocial-spiritual model in mental health.

Risk Prediction Models for Depression in Community-Dwelling Older Adults

OBJECTIVE

To develop streamlined Risk Prediction Models (Manto RPMs) for late-life depression.

DESIGN

Prospective study.

SETTING

The Survey of Health, Ageing and Retirement in Europe (SHARE) study.

PARTICIPANTS

Participants were community residing adults aged 55 years or older.

MEASUREMENTS

The outcome was presence of depression at a 2-year follow up evaluation. Risk factors were identified after a literature review of longitudinal studies. Separate RPMs were developed in the 29,116 participants who were not depressed at baseline and in the combined sample of 39,439 of non-depressed and depressed subjects. Models derived from the combined sample were used to develop a web-based risk calculator.

RESULTS

The authors identified 129 predictors of late-life depression after reviewing 227 studies. In non-depressed participants at baseline, the RPMs based on regression and Least Absolute Shrinkage and Selection Operator (LASSO) penalty (34 and 58 predictors, respectively) and the RPM based on Artificial Neural Networks (124 predictors) had a similar performance (AUC: 0.730-0.743). In the combined depressed and non-depressed participants at baseline, the RPM based on neural networks (35 predictors; AUC: 0.807; 95% CI: 0.80-0.82) and the model based on linear regression and LASSO penalty (32 predictors; AUC: 0.81; 95% CI: 0.79-0.82) had satisfactory accuracy.

CONCLUSIONS

The Manto RPMs can identify community-dwelling older individuals at risk for developing depression over 2 years. A web-based calculator based on the streamlined Manto model is freely available at https://manto.unife.it/ for use by individuals, clinicians, and policy makers and may be used to target prevention interventions at the individual and the population levels.

Mental state of demoralisation across diverse clinical settings: A systematic review, meta-analysis and proposal for its use as a 'specifier' in mental illness

OBJECTIVE

Demoralisation is a state of poor coping characterised by low morale, hopelessness, subjective incompetence, and loss of meaning and purpose in life. While studied extensively in oncology and palliative care, there has been recent exploration in broader medical and mental health settings. The aim was to investigate the prevalence of demoralisation and associated sociodemographic and psychological factors across these clinical settings.

METHOD

Six electronic databases were used to locate articles from January 2014 to March 2020. A pre-publication update of non-oncology populations was completed in September 2021. The review has been reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled prevalence of demoralisation was determined through % prevalence and mean demoralisation score; this was synthesised through meta-analysis of single means to determine pooled mean prevalence of Demoralisation Scale scores using the 'R' statistical software.

RESULTS

Demoralisation has been examined in 52 studies (n = 11,670) and found to be prevalent in 24-35% of oncology and non-oncology, including mental health, populations. The mean score on the Demoralisation Scale was 24.3 (95% confidence interval, CI = [21.3, 27.3]). There was evidence of divergent validity in addition to significant comorbidity between depression, demoralisation and suicidal ideation. Burdensome physical symptoms, and psychological and demographic factors are strongly correlated with demoralisation.

CONCLUSION

There remains a need to recognise demoralisation in various clinical and cultural settings and to strongly consider its inclusion as a 'specifier' within formal nosological systems for adjustment and depressive disorders. This is important to initiate targeted interventions and prevent significant morbidity.

Demoralization level fluctuated at various time frame of radiotherapy for patients with different cancers: a longitudinal observational study

Background

Demoralization is a psychological response that is frequently observed in patients with cancer or advanced diseases. It is affected by national characteristics, culture, disease characteristics and general conditions of the patient such as individual cultural features, nature of stress, personal expression preferences and social behavior. Compared with the results of previous studies on demoralization syndrome, patients with cancer in Taiwan exhibit a higher prevalence of demoralization. We aimed to investigate the prevalence of high demoralization and the changes in the level of demoralization in cancer patients during radiotherapy to explore the associated factors and the contributing factors to the high level of demoralization.

Methods

We used the Demoralization Scale-Mandarin Version to evaluate the demoralization level at six-time points in patients admitted for radiotherapy in a 3-month observational period. 101 patients allocated to three groups by cancer region completed the study. We applied the generalized estimating equation (GEE) to analyze the changes in the demoralization level among the three groups. The variables associated with the changes in the demoralization level were also investigated.

Results

In the analysis using univariate GEE, only patients in the chest and breast group exhibited significant changes at two different time points. The results obtained using multivariate GEE revealed that sociodemographic variables, stage of disease and use of surgery or chemotherapy had no impact on the changes in demoralization across three months.

Conclusion

The demoralization level certainly fluctuated in an extremely high range. The higher prevalence of demoralized patients may indicate that if medical staff neglect the importance of demoralization, demoralized patients with cancer may not receive appropriate care.

Depressive and anxiety symptoms in patients with COPD: A network analysis

BACKGROUND

Individuals with Chronic Obstructive Pulmonary Disease (COPD) often develop anxiety and depression, which worsen illness management and prognosis. Physical and psychological symptoms, contextual and illness-related factors display complex reciprocal interactions, which give rise to heterogeneous presentations. Examining the patterns of association between specific physical and psychological symptoms in patients with COPD may help to focus on the precision of the patient-centred care.

RESEARCH QUESTION

We used network analyses to examine the links between symptoms of COPD, depression and anxiety.

METHODS

Data from 1587 individuals with COPD from the COPDGene study were included. We estimated a Bayesian Gaussian Graphical Model to highlight the unique associations between symptoms of COPD (assessed with the COPD Assessment Test), depression and anxiety (assessed with the Hospital Anxiety and Depression Scale (HADS), while examining the role of sociodemographic characteristics, lung function tests, and health status.

RESULTS

Unique Variable Analysis reduced 14 HADS items to Tension/worry (chronic anxiety), Fear/panic (acute anxiety), Restlessness, Anhedonia, Sadness and Slowing. In network analyses, chest-tightness was related to acute anxiety, while cough and weakness were connected with core depressive symptoms (sadness and lack of pleasure). Chronic anxiety was linked with acute anxiety and depressive symptoms. Findings were confirmed accounting for the role of confounders, including lung function, sex, ethnicity and lifestyle factors. A simulation based on our model yielded distinct predictions about anxiety and depression in two participants with similar COPD severity, but different symptom profiles.

CONCLUSION

Network analyses highlighted specific associations between symptoms of COPD, depression and anxiety. Accounting for symptom-level interactions may help to promote personalized treatment approaches.

Demoralization in suicide: A systematic review

OBJECTIVE

In psychiatric literature, few original studies exist on the topic of demoralization in suicide. In this review, we aim to identify original studies on suicidal ideation (SI)/suicidal behavior (SB) and demoralization in populations of community-dwellers and patients with somatic or psychiatric disorders.

METHODS

We employed a systematic approach that followed PRISMA guidelines, searching through four major electronic databases (PubMed/MEDLINE, Scopus, Science Direct, and PsychINFO) for relevant titles/abstracts published from January 1980-June 2021. We included original studies that explicitly mentioned the investigation of a potential association between SI/SB and demoralization.

RESULTS

A total of 18 studies met our inclusion criteria. Their synthesis revealed that demoralization can be associated with SI/SB in a wide range of populations (community dwellers, patients with somatic or psychiatric disorders) and lead to significantly higher suicide risk (odds ratios of >6 were encountered in community dwellers experiencing financial hardship or isolation). Moreover, demoralization alone (about half the patients who were demoralized did not meet the criteria for an affective disorder nor were they clinically depressed) or together with depression has been identified as a major risk factor for SI/SB. Regarding the crucial issue of progression from SI to SA, in the context of the "ideation-to-action" frame, some authors found that the interaction of demoralization and over-arousal could be a useful predictor for this progression, while others found that depression alone was sufficient to differentiate attempters from non-attempters or the interaction with shutdown (helplessness and low positive emotions).

CONCLUSION

These results emphasize the possibility to identify demoralization as an independent risk factor for suicide. In patients with psychiatric disorders, the association between demoralization and SI/SB may be transnosographic. Overall, from the clinical implications perspective, our findings highlight that: i. Assessment of demoralization may contribute to a more comprehensive suicide risk detection. This appears particularly relevant in Emergency Departments (EDs) where heterogeneous population typologies are usually admitted and a clinical diagnosis of depression is often difficult to be defined. ii. Additionally, since meaninglessness is considered one of the demoralization subcomponents, meaning-centered psychotherapeutic approaches prove to be indicated and they can be initiated already at the EDs upon first contact with the patient. Further studies are necessary to confirm these findings.

Depressive symptom complexes of community-dwelling older adults: a latent network model

Late-life depression has multiple, heterogeneous clinical presentations. The aim of the study was to identify higher-order homogeneous clinical features (symptom complexes), while accounting for their potential causal interactions within the network approach to psychopathology. We analyzed cross-sectional data from community-dwelling adults aged 65-85 years recruited by the European MentDis_ICF65+ study (n = 2623, mean age 74, 49% females). The severity of 33 depressive symptoms was derived from the age-adapted Composite International Diagnostic Interview. Symptom complexes were identified using multiple detection algorithms for symptom networks, and their fit to data was assessed with latent network models (LNMs) in exploratory and confirmatory analyses. Sensitivity analyses included the Partial Correlation Likelihood Test (PCLT) to investigate the data-generating structure. Depressive symptoms were organized by the Walktrap algorithm into eight symptom complexes, namely sadness/hopelessness, anhedonia/lack of energy, anxiety/irritability, self-reproach, disturbed sleep, agitation/increased appetite, concentration/decision making, and thoughts of death. An LNM adequately fit the distribution of individual symptoms' data in the population. The model suggested the presence of reciprocal interactions between the symptom complexes of sadness and anxiety, concentration and self-reproach and between self-reproach and thoughts of death. Results of the PCLT confirmed that symptom complex data were more likely generated by a network, rather than a latent-variable structure. In conclusion, late-life depressive symptoms are organized into eight interacting symptom complexes. Identification of the symptom complexes of late-life depression may streamline clinical assessment, provide targets for personalization of treatment, and aid the search for biomarkers and for predictors of outcomes of late-life depression.

Psychometric Evaluation of the German Version of the Demoralization Scale-II and the Association Between Demoralization, Sociodemographic, Disease- and Treatment-Related Factors in Patients With Cancer

Objective: To test the psychometric properties, internal consistency, dimensional structure, and convergent validity of the German version of the Demoralization Scale-II (DS-II), and to examine the association between demoralization, sociodemographic, disease- and treatment-related variables in patients with cancer. Methods: We recruited adult patients with cancer at a Psychosocial Counseling Center and at oncological wards. Participants completed the 16-item DS-II, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Screener-2 (GAD-2), Distress Thermometer (DT), and Body Image Scale (BIS). We analyzed internal consistency of the DS-II using Cronbach's Alpha (α). We tested the dimensional structure of the DS-II with Confirmatory Factor Analyses (CFA). Convergent validity was expressed through correlation coefficients with established measures of psychological distress. The associations between demoralization, sociodemographic, disease- and treatment-related variables were examined with ANOVAs. Results: Out of 942 eligible patients, 620 participated. The average DS-II total score was M = 5.78, SD = 6.34, the Meaning and Purpose subscale M = 2.20, SD = 3.20, and the Distress and Coping Ability subscale M = 3.58, SD = 3.45. Internal consistency ranged from high to excellent with α = 0.93 for the DS-II total scale, α = 0.90 for the Meaning and Purpose subscale, and α = 0.87 for the Distress and Coping Ability subscale. The one-factor and the two-factor model yielded similar model fits, with CFI and TLI ranging between 0.910 and 0.933, SRMR < 0.05. The DS-II correlated significantly with depression (PHQ-9: r = 0.69), anxiety (GAD-2: r = 0.72), mental distress (DT: r = 0.36), and body image disturbance (BIS: r = 0.58). High levels of demoralization were reported by patients aged between 18 and 49 years (M = 7.77, SD = 6.26), patients who were divorced/separated (M = 7.64, SD = 7.29), lung cancer patients (M = 9.29, SD = 8.20), and those receiving no radiotherapy (M = 7.46, SD = 6.60). Conclusion: The DS-II has very good psychometric properties and can be recommended as a reliable tool for assessing demoralization in patients with cancer. The results support the implementation of a screening for demoralization in specific risk groups due to significantly increased demoralization scores.

Bridging late-life depression and chronic somatic diseases: a network analysis

The clinical presentation of late-life depression is highly heterogeneous and likely influenced by the co-presence of somatic diseases. Using a network approach, this study aims to explore how depressive symptoms are interconnected with each other, as well as with different measures of somatic disease burden in older adults. We examined cross-sectional data on 2860 individuals aged 60+ from the Swedish National Study on Aging and Care in Kungsholmen, Stockholm. The severity of sixteen depressive symptoms was clinically assessed with the Comprehensive Psychopathological Rating Scale. We combined data from individual clinical assessment and health-registers to construct eight system-specific disease clusters (cardiovascular, neurological, gastrointestinal, metabolic, musculoskeletal, respiratory, sensory, and unclassified), along with a measure of overall somatic burden. The interconnection among depressive symptoms, and with disease clusters was explored through networks based on Spearman partial correlations. Bridge centrality index and network loadings were employed to identify depressive symptoms directly connecting disease clusters and depression. Sadness, pessimism, anxiety, and suicidal thoughts were the most interconnected symptoms of the depression network, while somatic symptoms of depression were less interconnected. In the network integrating depressive symptoms with disease clusters, suicidal thoughts, reduced appetite, and cognitive difficulties constituted the most consistent bridge connections. The same bridge symptoms emerged when considering an overall measure of somatic disease burden. Suicidal thoughts, reduced appetite, and cognitive difficulties may play a key role in the interconnection between late-life depression and somatic diseases. If confirmed in longitudinal studies, these bridging symptoms could constitute potential targets in the prevention of late-life depression.

Exploring the Level of Post Traumatic Growth in Kidney Transplant Recipients via Network Analysis

Although kidney transplant can lead to psychiatric disorders, psychosocial syndromes and demoralization, a positive post-traumatic growth (PTG) can occur in kidney transplant recipients (KTRs). However, the PTG-Inventory (PTGI), a reliable tool to measure PTG is scarcely used to explore the effect of this stressful event in KTRs. Thus, the purpose of our study was to assess the level of PTG and its correlation with demoralization, physical and emotional symptoms or problems via network analysis in KTRs. Additionally, we aimed at exploring the association of PTG with psychiatric diagnoses, Diagnostic Criteria for Psychosomatic Research (DCPR) conditions, and medical variables. A total of 134 KTRs were tested using MINI International Neuropsychiatric Interview 6.0 (MINI 6.0), DCPR interview, PTGI, Edmonton Symptom Assessment System (ESAS), Canadian Problem Checklist (CPC) and Demoralization scale (DS-IT). PTGI was used to investigate the positive psychological experience of patients after KT. It consists of 21 items divided in five factors. Routine biochemistry, immunosuppressive agents, socio-demographic and clinical data were collected. A symptom network analysis was conducted among PTGI, ESAS and DS-IT. Mean score of PTGI total of sample was 52.81 ± 19.81 with higher scores in women (58.53 ± 21.57) than in men (50.04 ± 18.39) (p < 0.05). PTGI-Relating to Others (16.50 ± 7.99) sub-score was markedly higher than other PTGI factor sub-scores. KTRs with DCPR-alexithymia or International Classification of Diseases, tenth revision (ICD-10) anxiety disorders diagnosis had lower PTGI total score and higher PTGI-Personal Strength sub-score, respectively (p < 0.05). The network analysis identified two communities: PTGI and ESAS with DS-IT. DS-IT Disheartenment, DS-IT Hopelessness and PTGI Relating to Others were the most central items in the network. After 1000 bootstrap procedures, the Exploratory graph analysis revealed the presence of a median of two communities in the network in 97.5% of the bootstrap iterations. A more extensive use of PTGI should be encouraged to identify and enhance the positive psychological changes after KT.